femoral neck fractures 主讲教师 : 欧阳宏伟 / 蔡友治 浙江大学医学院
TRANSCRIPT
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Femoral Neck Fractures
主讲教师 : 欧阳宏伟 / 蔡友治
浙江大学医学院
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High energy injury
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Low energy injury
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• An 81-year-old • Female• complaining of hip
pain and inability to walk after a simple fall.
Case 1
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A 47-year-old female with a history of schizophrenia and alcoholism complaining of hip pain and inability to walk after a fall. The affected leg appeared slightly shorter than the contralateral leg, and any attempted movement was painful.
Case 2
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Case 3 82-year-old
female
complaining of hip pain after an unwitnessed fall.
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Case report
• A girl fall from a high tree
• Result: simultaneous bilateral fractures of the femoral neck
• process: initially they fall on edge of the roof or on branch of tree fracturing one neck of femur before falling to the ground to fracture the other.
How happened?
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Anatomy
Physeal closure age 16 Neck-shaft angle 130° ± 7° Anteversion 10° ± 7° Calcar Femorale
– Posteromedial– dense plate of bone
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Anatomy
anteversion
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Anatomy
calcar femorale
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Anatomy
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Blood Supply
Intracapsular are at risk of non union and avascular necrosis due to interruption of the blood supply to the femoral head
– Via cruicate (med and lat circumflex) and intramedullary.
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Muscular balances
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Muscular balances
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Muscular balances
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Muscular balances
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Muscular balances in hip
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What’s the mechanism?
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Bone Load and Response
•Stress– force per unit area
•Strain– deformation
• amount of deformation divided by original length
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Types of Forces
TensileCompressiveBendingShearTorsion
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Compressive Loading(pushing, compressing forces)
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Stress, or pressure (): force per unit areaHow much force does it take to cause an effect?
That depends on how much area the force is spread over.
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Localize Force with Pisiform Contact
(Greater stress because contact area is smaller)
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The concept of strain also applies to compressive loads
LL
If the original length (L) was 300 mm and
the new length was was 291 mm then
= L / L = (new length – original length) / original length
= (291 mm – 300 mm) / 300 mm = -9 / 300
= -0.03, or -3%
Strain by itself tells you nothing about stress
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Compressive load compression fracture
Compression Fracture of C5 Bilateral Compression of Femoral Necks
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Stress-Strain Relationship
Strain (deformation)
Str
ess
(loa
d)El
astic
Reg
ion
Elastic Limit
Plastic Region
GenericGeneric
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Stress-Strain Relationship
Strain (deformation)
Str
ess
(loa
d)E
last
ic R
egio
n FractureThreshold
Plastic Region
BoneBone
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Relative Bone StrengthS
tres
s to
Fra
ctu
re
Load Type
Com
pres
sion
Ten
sion
She
arFractures: with excessive loads, bone tends to fracture on the side loaded in tension.
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Bone Response to Stress
Wolff's law (1892)– tissue adapts to level of imposed stress
• increased stress– hypertrophy (increase strength)
• decreased stress– atrophy (decrease strength)
– Shape reflects function• Genetics, Body weight, physical activity,
diet, lifestyle (see note clippings)
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Protecting our Bones in Sport
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The pattern ofTrbecular bone in the greater trochanter neck of the femur head of the femur reflects femur’s roles:muscle attachment flexibility weight transfer support
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Atrophy in Bone
Weight & strength decreaseWeight & strength decrease– Calcium content diminishesCalcium content diminishes
• Reduced BMDReduced BMD– Trabecular integrity is lostTrabecular integrity is lost
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Bone stimulating factors
Rate of loadingMagnitudeFrequency
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BMD and walking
Quartiles based on miles walked/week
Krall et al, 1994, Walking is related to bone density and rates of bone loss. AJSM, 96:20-26
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Biomechanics
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One mechanism for reducing the resultant load on the femoral head is the use of a walking stick in the opposite hand.
Biomechanics
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Biomechanics of Cane
Cane in Contralateral hand decreases JRF
Long moment arm makes so effective
15% BW to cane reduces joint contact forces by 50%
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Fracture mechanism
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Fracture mechanism
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Fracture mechanism
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Fracture mechanism
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Fracture mechanism
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Fracture mechanism
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Blood supply insufficiently
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Fracture mechanism
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Garden Classification
Garden I: incomplete fracture of the femoral neck
Garden II: complete fracture without displacement
Garden III: complete fracture with partial displacement
Garden IV: complete fracture with full displacement
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Fracture of femur neck
• Geriatric population – simple fall
• Younger population – high energy injury
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Risk Factors Age: >65 years Co-morbid factors: osteoporosis, endocrine disorders
(hyperthyroidism, hypogondaism), GIT disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons, MS)
Gender: F RTA
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Risk Factors Nutrition: lack of calcium and Vit
D in diet, eating disorders (anorexia), high caffeine intake
Smoking Alcohol Medication: steroids,
anticonvulsants, diuretics Environmental factors: loose
rugs, dim lighting, cluttered floors
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TreatmentOptions
– Non-operative• very limited role• Activity modification• Skeletal traction
– Operative• ORIF• Hemiarthroplasty• Total Hip Replacement
biological therapy
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Management
Conservative: analgesia, bed rest, traction–if pt not willing to consent for surgery or if
not expected to survive surgery
Surgical: Manninger et al showed significant reduction in osteonecrosis and segmental collapse if performed within 6 hr–Head sparing: screws, DHS–Head sacrificing: hemi, THR
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Young Patients
Non-displaced fractures• At risk for secondary displacement• Urgent ORIF recommended
Displaced fractures• Patients native femoral head best• AVN related to duration and degree of
displacement• Irreversible cell death after 6-12 hours• Emergent ORIF recommended
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Elderly PatientsOperative vs. Non-operative
–Displaced fractures • Unacceptable rates of mortality, morbidity, and
poor outcome with non-operative treatment
–Non-displaced fractures • Unpredictable risk of secondary displacement
– AVN rate 2X
–Standard of care is operative for all femoral neck fractures• Non-operative tx may have developing role in
select patients with impacted/ non-displaced fractures
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Acceptable Reduction
Lowell’s Alignment theory– outline of femoral head
& neck junction will have convex outline of femoral head meeting concave outline of femoral neck regardless on all views
– Image should produce an S or reverse S
– If image is a C fracture is not reduced
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Garden Alignment Index
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Treatment choices:
1: Cannulated Hip screws.
2: Dynamic Hip Screw.
3: Cephalo-medullary device.
4: Hemiarthroplasty Hip.
5: Total Hip Replacement.
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operations
ORIF
Hemi
THR
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Cannulated Screws
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Cannulated Screws
Good Bad
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Dynamic Hip Screw
Good for fracture with more vertical fracture line
Problem w this is that cannulated screw will prevent fracture impaction non union
Sacrifices large amount of boneAnti-rotation screw often needed
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Hemi Vs. THR• Dislocation rates:
– Hemi 2-3% vs. THR 11% (short term)• 2.5% THR recurrent dislocation (Cabanela1999)
• Reoperation:– THR 4% vs. Hemi 6-18%
• DVT / PE / Mortality – No difference
• Pain / Function / Survivorship / Cost-effectiveness• THR better than Hemi (Iorio 2001)
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Complications
Failure of Fixation• Inadequate / unstable reduction• Poor bone quality• Poor choice of implant
Treatment–Elderly: Arthroplasty–Young: Repeat ORIF
Valgus-producing osteotomy Arthroplasty
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讲者简介
• 蔡友治 03 级浙大临床七年制• 浙大附属第一医院骨科运动医学中心 医生• 专注于运动创伤微创诊治及创新性医疗手段的研发 .• 目前在干细胞及纳米组织工程领域有一定深入研究。• 发表 SCI 及中华医学期刊十几篇,负责国家自然科学基金一项(在研),并
参与多项科研基金。• Email : [email protected]• TEL : 13588270341
运动让生命更健康 医学让运动更美好